Provider Demographics
NPI:1346865730
Name:SERNA, DENISE
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:SERNA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 W 75TH PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60652-1303
Mailing Address - Country:US
Mailing Address - Phone:773-655-0493
Mailing Address - Fax:
Practice Address - Street 1:3805 W 75TH PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60652-1303
Practice Address - Country:US
Practice Address - Phone:773-655-0493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-11
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207373747Medicaid